Method of mending a groin defect

ABSTRACT

A method of mending a groin defect such as an indirect inguinal hernia, a direct inguinal hernia, and/or a femoral hernia. A space between the external oblique aponeurosis and the internal oblique aponeurosis is dissected superiorly and laterally to create a site for receiving a lateral portion of a prosthetic repair patch. Dissection medially and inferiorly between the two aponeuroses leads to a transversalis fascia, which is explored downwardly and, at the pubic bone, dissected to reach the preperitoneal space of Retzius. A medial portion of a prosthetic repair patch may be positioned in the space of Retzius with a lateral portion of the prosthetic repair patch positioned in the dissected space between the two aponeuroses. So positioned, the prosthetic repair patch protects the myopectineal orifice that is susceptible to each of the indirect inguinal hernia, direct inguinal hernia, and femoral hernia.

RELATED APPLICATIONS

This application claims the benefit under 35 U.S.C. §120 of U.S.application Ser. No. 14/480,690, entitled “METHOD OF MENDING A GROINDEFECT” filed on Sep. 9, 2014, which is herein incorporated by referencein its entirety. Application Ser. No. 14/480,690 claims the benefitunder 35 U.S.C. §120 of U.S. application Ser. No. 13/544,072, entitled“METHOD OF MENDING A GROIN DEFECT” filed on Jul. 9, 2012, which isherein incorporated by reference in its entirety.

FIELD

The field relates to surgical procedures and, more specifically, to asurgical method for mending a groin defect.

BACKGROUND

Groin hernias are typically characterized as indirect inguinal hernias,direct inguinal hernias, and femoral hernias. It is known to repair suchhernias by covering the defect with a prosthetic repair patch. In theclassic ‘Lichtenstein’ procedure, the patch is placed anteriorly of thetransversalis fascia. Alternatively, the patch may be positionedposteriorly of the transversalis fascia, between the transversalisfascia and the peritoneum—this location being known as the‘preperitoneal space’. A prosthetic repair patch may be deliveredlaparoscopically to the preperitoneal space in a procedure known asTEP—“Totally Extra Peritoneal”. Alternatively, a prosthetic repair patchmay be placed in the preperitoneal space via an ‘open’ procedure. Twocommon open procedures for preperitoneal placement of a prostheticrepair patch include the POLYSOFT Hernia Patch procedure and the Kugelprocedure. In the POLYSOFT approach, access to the preperitoneal spaceis through the defect itself. In the Kugel procedure, an opening isformed directly through the three layers overlying the preperitonealspace—the external oblique aponeurosis, the internal obliqueaponeurosis, and the transversalis fascia. In both the POLYSOFTprocedure and the Kugel procedure, the prosthetic repair patch ispositioned in a single tissue plane between the peritoneum and thetransversalis fascia.

SUMMARY

Methods are provided for mending a groin defect, specifically defects ofthe myopectineal orifice including an indirect inguinal hernia, directinguinal hernia, and/or a femoral hernia. In certain aspects, a methodis provided for reaching a preperitoneal space without having topenetrate through a groin defect and without having to dissect throughthe internal oblique aponeurosis. In other aspects, a method ofrepairing a groin defect is provided where a prosthetic repair patch ispositioned in two different tissue planes in the groin region; only oneof the tissue planes being preperitoneal.

In one embodiment, a method of mending a groin defect includesdissecting inferiorly between an external oblique aponeurosis and aninternal oblique aponeurosis to reach the transversalis fascia, and thendissecting through the transversalis fascia at the area of the pubicbone into the preperitoneal space, such as the space of Retzius. Themethod may further include implanting a prosthetic repair patch thatextends from the preperitoneal space to the dissected area between theexternal oblique aponeurosis and an internal oblique aponeurosis.

In another embodiment, a method of mending a groin defect includespositioning a medial portion of a prosthetic repair patch posteriorly ofa transversalis fascia in a preperitoneal space, and positioning alateral portion of the prosthetic repair patch anteriorly of thetransversalis fascia. More particularly, the method may include an openprocedure where a lateral portion of the prosthetic repair patch isplaced in a surgically created space between the external obliqueaponeurosis and the internal oblique aponeurosis, and a medial portionof the prosthetic repair patch is placed in the space of Retzius.

In a further embodiment, a method of mending a groin defect includes, inan open procedure, creating an access through a transversalis fascia andinto a preperitoneal space, such as the space of Retzius, and thenpositioning a portion of a prosthetic repair patch in the preperitonealspace and another portion of the prosthetic repair patch anteriorly ofthe transversalis fascia.

The foregoing is a non-limiting summary of the invention, which isdefined by the attached claims. Other aspects, embodiments, featureswill become apparent from the following description.

BRIEF DESCRIPTION OF DRAWINGS

Various embodiments of the invention will now be described, by way ofexample, with reference to the accompanying drawings, in which:

FIG. 1 is an illustration of a prosthetic repair patch extending frombehind the pubic bone in the space of Retzius to a dissected spacebetween the external oblique aponeurosis and the internal obliqueaponeurosis;

FIG. 2 is another illustration of a prosthetic repair patch implantedaccording to the present procedure; and

FIG. 3 is an illustration of a representative repair patch for use inthe disclosed procedure for mending a groin defect.

DETAILED DESCRIPTION

It should be understood that aspects of the invention are describedherein with reference to the figures, which show illustrativeembodiments in accordance with aspects of the invention. Theillustrative embodiments described herein are not necessarily intendedto show all aspects of the invention, but rather are used to describe afew illustrative embodiments. Thus, aspects of the invention are notintended to be construed narrowly in view of the illustrativeembodiments. It should be appreciated, then, that the various conceptsand embodiments discussed herein may be implemented in any of numerousways, as the disclosed concepts and embodiments are not limited to anyparticular manner of implementation. In addition, it should beunderstood that aspects of the invention may be used alone or in anysuitable combination with other aspects of the invention.

An open procedure is described for mending a groin defect including, butnot limited to, one or more of an indirect inguinal hernia, a directinguinal hernia, a femoral hernia and/or other weakness or rupture ofthe groin anatomy. The phrase “mending a groin defect” includes acts ofrepairing, augmenting, and/or reconstructing a groin defect and/or apotential groin defect. Although the open procedure is described inconnection with placing a prosthetic repair patch at the defect site,the treatment is not so limited and other medical responses to a defectof the groin that employ the surgically created pathway disclosed hereinalso are contemplated.

In one embodiment, an open procedure creates a space between theexternal oblique aponeurosis 1 and the internal oblique aponeurosis 2superiorly and laterally to an incision site. This space may beconfigured to receive a lateral portion 11 of a prosthetic repair patch.Medially and inferiorly of the dissected space between the two obliqueaponeuroses, and remote from the groin defect, the transversalis fascia3 is penetrated to reach the space of Retzius 8—an area located deep ofthe pubic bone 5 and anteriorly of the peritoneum 4. A surgicallycreated pathway now runs from the space of Retzius 8, a preperitonealspace, to the dissected area between the external oblique aponeurosis 1and the internal oblique aponeurosis 2. A patch may be implanted alongthis pathway, with a lateral portion 11 positioned in the dissectedspace between the external oblique aponeurosis and the internal obliqueaponeurosis and a medial portion 6 extending through the transversalisfascia to the preperitoneal area of the pubic bone 5. An intermediateportion runs with the spermatic cord, extending transversely between themedial and lateral portions of the prosthetic repair patch. A slit maybe provided in the lateral portion to define two separable portions,referred to as “tails”, that may be spread apart to accommodate thespermatic cord. Subsequently, the tails are reunited and, if desired,sutured together or otherwise secured.

More specifically, a representative procedure for treating an inguinalhernia, whether an indirect or direct inguinal hernia, will now bedescribed. A small transverse incision, approximately 3 cm long, is madeabout two fingers breadths above and lateral to the pubic synthesis. Theincision is lateral to the rectus muscles and avoids the superficialanterior branches of the iliohypogastric nerve and the femoral branch ofthe genitofemoral nerve. The anterior surface of Scarpa's fascia is thenexposed. Blunt dissection of Scarpa's fascia exposes the anteriorsurface of the external oblique aponeurosis 1. Further dissection of theexternal oblique aponeurosis exposes the underlying internal obliqueaponeurosis 2—which is not dissected or otherwise opened. Dissectionproceeds between the two oblique aponeuroses laterally and superiorly toapproximately the superior iliac spine; for example, the surgeon'sfinger may be swept between the respective tissue planes, creating aspace to receive a lateral portion 11 of a prosthetic repair patch.Medially, a probing finger facing upwards is swept to identify thespermatic cord 10, which is then elevated out of the incision. The cordis explored for the presence of an indirect hernia and, if found, thesac contents are reduced and the excess sac ligated or removed asappropriate. If a direct hernia is identified, the sac and contents maybe reduced into the abdominal cavity. The transversalis fascia 3 is thendigitally explored down to the public bone 5. Here, the transversalisfascia 3 is penetrated, for example, by plunging the surgeon's fingerthrough the fascia to create an opening that leads to the preperitonealspace of Retzius 8. The space of Retzius 8 may be dissected to configurethe location for receipt of a medial portion 6 of a prosthetic repairpatch. A sterile gauze may be inserted into the incision and advanceddown towards the pubic bone to bluntly dissect the space that willreceive the prosthetic repair patch.

A medial portion 6 of a prosthetic repair patch can now be advanced downthe surgically created access to the preperitoneal space of Retzius 8behind the pubic bone 5, while a lateral portion 11 of the patch can nowbe located in the dissected space between the external and internaloblique aponeuroses. An intermediate portion of the patch runs down fromthe lateral portion along the spermatic cord 10 and posteriorly of thetransversalis fascia 3 to the medial portion 6, such that the implantedpatch may approximate an S-shape as shown in FIG. 2. The patch should besufficiently flexible to allow placement of portions of the patch in andalong these different tissue planes. No fixation of the medial orlateral portions of the patch is required. With the prosthetic repairpatch in place and covering one or more of the groin defects of interestand, in certain embodiments, completely protecting the myopectinealorifice so as to extend about all of the areas susceptible to indirectinguinal hernia, direct inguinal hernia and femoral hernia, the externaloblique aponeurosis and the initial incision may be closed, such as bysuturing, stapling and the like.

A representative prosthetic repair patch suitable for use in thisprocedure includes the POLYSOFT Hernia Patch available from Davol Inc.,a subsidiary of C.R. Bard, Inc. The POLYSOFT Hernia Patch includes abody portion of tissue infiltratable knit fabric, such as BARD MESH, andan interrupted memory recoil ring that is integrated with the bodyportion to facilitate manipulation and deployment of the patch. A slitmay be provided in the patch between the interrupted ends of the ring tocreate a pair of separable tails for accommodating the spermatic cord.The POLYSOFT Hernia Patch is sized to protect the myopectineal orificeand, thus, the anatomy susceptible to indirect hernia, direct hernia andfemoral hernia; however, patches that are configured to protect only oneor more of these groin regions of interest also are contemplated. ThePOLYSOFT Hernia Patch, a planar-type patch with an oval configuration,is shown in FIG. 3.

The patch may be formed of any fabric suitable for repair oraugmentation of a soft tissue defect. Without limiting the foregoing,the fabric may constitute a resorbable material, a permanent material,or a hybrid of resorbable and permanent materials. Non-limiting examplesof resorbable fabric materials include resorbable polyesters such aspolyglycolic acid (PGA), polylactic acid (PLA), poly(lactic-co-glycolicacid) (PLGA), polydioxanone (PDO), polycaprolactone (PCL), any otherresorbable polyester, polyhydroxyalkanoate (PHA), as well as collagen,calcium alginate and combinations of any of the foregoing. Permanentfabric materials include polypropylene, polyethylene, polyester,polytetrafluoroethylene, and other non-resorbable polymers havingapplication in soft tissue repair fabrics. Some or all of the patch maybe configured to promote tissue ingrowth into interstices of the patchand/or around the patch, or to discourage same. Thus, the patch may beporous, micro-porous, or essentially non-porous, and different regionsof the patch may have different porosity characteristics. If desiredsome or all of the surfaces of the patch may include a barrier that isresistant to adhesions with sensitive organs or tissue. The patch may beloaded with one or more medicinal or therapeutic agents including, butnot limited to, an analgesic or antibiotic. The patch may be formed ofone or more layers, with the layers having the same or differentproperties including, but not limited to, material composition. Thepatch may in the form of a planar-like sheet, and may be configured withconvexity, concavity, a combination of convexity and concavity, andother shapes. As observed earlier, the patch may be flexible tofacilitate placement of portions of the patch in different tissueplanes. As in the POLYSOFT Hernia Patch, the patch for use in thedisclosed methodology may include a ring or other support feature to aidin handling and deployment thereof. Such a ring may be made of apermanent or a resorbable material.

It should be understood that the foregoing description of variousembodiments of the invention are intended merely to be illustrativethereof and that other embodiments, modifications, and equivalents ofthe invention are within the scope of the invention recited in theclaims appended hereto.

What is claimed is:
 1. A method of mending a groin defect, comprisingthe acts of: creating an incision superior and lateral to the pubicsynthesis; externalizing a spermatic cord through the incision; locatingthe spermatic cord between two separable portions of a prosthetic repairpatch; implanting a lateral portion of the prosthetic repair patch at afirst tissue plane in a groin region; and implanting a medial portion ofthe prosthetic repair patch at a second tissue plane in the groinregion, the second tissue plane being posterior to the first tissueplane.
 2. The method recited in claim 1, wherein the act of locatingincludes spreading apart separable portions of a lateral portion of theprosthetic repair patch.
 3. The method recited in claim 2, furthercomprising the act of securing the separable portions together afterthey have been spread apart and the spermatic cord located therebetween.4. The method recited in claim 1, wherein the lateral portion implantingact and the medial portion implanting act include forming the prostheticrepair patch into an S-shape.
 5. The method recited in claim 1, whereinthe first tissue plane is anterior of a transversalis fascia.
 6. Themethod recited in claim 5, where the first tissue plane is between theexternal oblique aponeurosis and the internal oblique aponeurosis. 7.The method recited in claim 1, where the second tissue plane isposterior of a transversalis fascia.
 8. The method recited in claim 7,wherein the second tissue plane is preperitoneal.